Don Berwick is an American hero and also a victim of the obscene stalemate in Washington; the one being heaped on us by our Congress that has a 9% approval rating. Most people that I know with a score that low would have the self-respect to quit rather than to point fingers at others. Well, as part of this mess, Congress wouldn't approve the appointment of Dr. Don Berwick, who is a true American hero because he is among one of the real leaders of the movement to save American health care. Before coming to Washington, the organization he led, a small non-profit called the Institute for Health Improvement, organized and guided an effort in American hospitals that -- by doing simple, evidence things like hand washing, raising the bed when people are on a respirator, and other small but effective things -- saved more than 100,000 lives by some estimates. This little non-profit recruited over 3000 hospitals that had over 70% of the beds in the U.S. to participate in this effort to reduce preventable deaths.

Obama, recognizing his greatness, appointed him as head of the Centers for Medicare and Medicaid Services. Or he tried to. Our do nothing -- or actually do nothing but screw the other side -- Congress opposed his appointment, so Obama did one of those sneaky interim appointments that Berwick to keep the position for 17 months before being forced out. The New York Times Joe Nocera did a great piece on him, check it out.

The thing I would especially emphasize is that Berwick is not and has never been about ideology, he is about effectiveness and cost-cutting is central to everything he does and advocates. Perhaps he wasn't mean and tough and selfish enough for our broken system; it is a shame that a guy who does everything possible to put patients first would be fired by people who do everything they can to put themselves first.

I urge you to read his amazing farewell address. Get it here: Download Ihi forum don berwick 12-15.dat.Consider a few key parts. Here are his five principles -- and unlike people in Congress who TALK about doing things -- Berwick's organization has already led efforts to DO such things and continues to do so every day. He gets fired and they keep their jobs? I quote:

This is our task… our unwelcome task – if we are to help save health care from the cliff. To reduce costs, by reducing waste, at scale, everywhere, now.

I recommend five principles to guide that investment:

1. Put the patient first. Every single deed – every single change – should protect, preserve, and enhance the well beingof the people who need us. That way – and only that way – we will know waste when we see it.

2. Among patients, put the poor and disadvantaged first –those in the beginning, the end, and the shadows of life. Let us meet the moral test.

3. Start at scale. There is no more time left for timidity. Pilots will not suffice. The time has come, to use Göran Henrik’sscary phase, to do everything. In basketball, they call it “flooding the zone.” It’s time to flood the Triple Aim zone.

4. Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the partiesburdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.

5. Act locally. The moment has arrived for every state,community, organization, and profession to act. We need mobilization – nothing less.

To show these aren't just theories or pipe dreams, look at these examples from Dr. Berwick's speech:

It is not possible to claim that we do not know what to do. We have the templates.

If you doubt it, visit the brilliant Nuka care system at Southcentral Foundation in Anchorage, which just won the Baldrige Award. I visited in October. Thoroughly integrated teams of caregivers –physicians, advanced practice nurses, behavioral health specialists, nutritionists, and more – occupying open physical pods in line-of-sight contact with each other all day long, weaving a net of help and partnership with Alaska Native patients and families. The results: 60% fewer Emergency and Urgent CareVisits, 50% fewer hospitalizations, and 40% less use of specialists, along with staff turnover 1/5th as frequent as before the new care.

If you doubt that we know what to do, visit Denver Health or ThedaCare or Virginia Mason, and see the Toyota principles of lean production learned, mastered, adapted, and deployed through entire systems and into the skills and psyches of entire workforces. The result, over $100 million in savings at Denver Health while vastly improving the experience and outcomes of patients.

If you doubt that we know what to do, contact George Halvorson at Kaiser Permanente and ask him how they have reduced sepsismortality – sepsis is the cause of death in 24% of seniors who die in California hospitals. Kaiser-Permanente has driven down sepsis mortality by nearly half – to 11% in less than three years.

Then, Berwick said to the colleagues he was leaving at the Centers for Medicare and Medicaid Services:

Let me put it simply: in this room, with the successes already in hand among you here, you collectively have enough knowledge to rescue American health care – hands down. Better care, better health, and lower cost through improvement right here. In this room.

The only question left is: Will you do it?

Shame on us as a country for allowing this man to be fired and for bickering and backstabbing while the solutions appear to be at hand. Can't we join together to do the right things?

I do not know anything about Mr. Berwick. However, as I look at his list of 5 things I don't see how any of these 5 things meets his stated goal in the paragraph that immediately preceeded it, namely: "To reduce costs, by reducing waste, at scale, everywhere, now."

1. Putting the patient first is certainly an important goal. But to state that doing so is the only way we will know waste when we see it? Why is that? That doesn't sound evidence based. It sounds a little like wishful thinking.

2. Putting the poor first to meet the moral test? Why is that moral? Should those of means be treated worse than those without? This is a moral judgement and one that doesn't relate to the stated goal of reducing costs either.

3. Start at scale and do everything? So rather than identify areas for improvement he is proposing to radically alter the entire system by "flooding the zone". And what evidence based research suggests that radical change is more likely to be successful than incremental improvement. Mind you we are not talking about a system full of failures. We are talking about a system the provides excellent health care at a higher than average cost. Are we to believe the best approach in that instance is radical change by "flooding the zone" whatever that phrase is supposed to mean?

4. Return the money by making the bill which is paid by all parties fall? Wait a minute. The first rule of definitions is you cannot be self referential. You actually have to propose a means to reduce costs. Saying you are going to reduce costs by making the bill fall is not proposing anything. The fact that such a meaningless statement could make his top 5 list is quite concerning.

5. Act locally. Ok, that may be fine. Not exactly sure what that means so I would need to see more details to see if there is anything here that could be thought to reduce costs. As it stands the idea seems fine but not sure if there is any good reason to believe it is either cost reducing or even possible in a system with so many non-local requirements.

As I said, I am not familiar with Mr. Berwick. He may be everything he has been promoted to be here. If so, this list is far from his best work. However, I certainly wouldn't hire him based on it.

The idea of "cutting costs" threatens to upend the status quo of medical care in America, which is currently awful for the patient, but very lucrative for several other parties. Those parties happen to have a lot of money, which they also happen to contribute to members of Congress. Since those members need the money to get re-elected, it's unlikely we'll see anyone that isn't dedicated to the massive profit margins of insurance companies and medical institutions in that position.

Now Bob, your hope and altruism are showing. I have had a framed cross-stitch piece on my office wall given to me by wife a very long time ago which reads, "The one who says it can't be done should never interrupt the one who is doing it." Or in other words, illigetimi non carborundum. Great post.

Bob:
Thanks for the heads up on this very moving transcript for Don Berwick's speech. He had so much influence with his 100,000 lives campaign. As a Canadian his principles just make good sense just for the health of it!
David